Author Archives: hospitalcio

Thoughts About The Cloud

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There is a lot of buzz about “the cloud,” as there should be. Still, it is amazing to me how the hype, especially IT company advertising, seems to miss the mark. Here is an example, the Microsoft commercial with the couple stuck in the airport.

They are able to use “the cloud” to remote into their home PC to watch a video. I think this commercial sucks for the following reasons:

  • In my opinion, this is not using the cloud. I will explain my definition below.
  • Watching video over a remote connection is like taking a shower with your clothes on. It sort of works, but the experience is awful.
  • Few people use Microsoft technologies to record TV. It would have been more realistic (and more cloud-like) if they downloaded TV using iTunes, or Amazon.
  • If you want me to empathize with this beautiful couple, don’t have them watch “Celebrity probation.” I have my share of guilty pleasures, but still…

Worst of all, this ad obfuscates what the cloud means. I suspect Microsoft’s only goal is to associate their name with the cloud. What the couple is actually doing may be irrelevant to Microsoft marketing types.

Nothing Microsoft does in this commercial helps us better understand “the cloud” and why is it noteworthy.

Everyone has their own definition of the cloud and typically they are written in a way that justifies their interests. To me The Cloud is a means to deliver an application as an IT service, where:

1. the service is hosted on servers and storage that are not on our private network
2. those servers and storage are connected to our private network via the Internet
3. the application is accessed by the user using a standard browser without any plug-ins, active-x controls or java requirements. Just HTML5.

I don’t believe in private clouds, or other variations. That strikes me as market-speak that organizations use to make their products and services seem like they are part of the hype. The cloud is not about watching bad TV with a massive latency and audio synch problems while we are sitting on airport carpet.

The cloud is about buying IT as a service to shift time and focus away from:

  • deploying and managing data centers; and
  • installing and troubleshooting desktop software.

Spending less time on these technical things should allow a business to focus on leveraging IT to drive even greater business value.

Attitude Adjustment

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My car was being repaired on Wednesday, so I took the bus home from work. Fortunately, the main bus terminal is one block from our IT offices in Appleton. Unfortunately, the closest the bus gets to my house is over a mile a way.

I jumped on the bus looking forward to getting a little exercise with a crisp fall walk. By the bus arrived at my stop it was snowing hard and snow was accumulating on the sidewalk. I was feeling so sorry for myself I almost didn’t notice the person that got off the bus at the same time. When I did, he was smiling and trying to catch my attention. I returned the smile he went on to tell me that he was so happy to see the snow.  It turns out he is a college student, on an exchange program from Guatemala, learning Business and English. He had never seen snow before. We shared much of the same path and time and weather seemed to disappear from my list of concerns as we had a pleasant conversation as we walked. Seeing his joy in what I was dreading completely changed my attitude.

At work attitudes are so powerful. Not only does a manager set the tone with their attitude and non-verbal signals. But all employees’ attitudes have so much influence over how a meeting is perceived. I value every employee’s opinion and when they appear uninterested or disagreeable, I cannot help be affected by that. Luckily, the folks I work with are supportive people.

Being a good listener and bringing a sense of excitement to your work is powerful. When I was relatively new to the workforce I remember listening to a fellow employee present some information. Whenever she missed a fact I would shake my head no. After a while I realized this was having a negative on her presentation (duh). Since then I always try to be a good listener. If someone is presenting and I am not expected to engage them in dialogue, I look them in the eye, I shake my head affirmatively and I smile. I know this puts people at ease which allows them to be their best.

Building Team Skills to Win The EHR War

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I had the pleasure of being in a small audience to hear Wisconsin’s own Quint Studer speak. Most healthcare folks will recognize Quint as the guru of approaches to achieve great results in hospitals (patient satisfaction, employee engagement, financial performance and quality).

Quint criticized healthcare organizations that have tried to address financial challenges by reducing training budgets. I have been guilty of this short-sightedness in the past. However it is now clear to me that the only way we can continue to address the continually increasing demand for IT is to better leverage our employees. As we ask more employees to lead more complex projects they need the support and education to be successful.

I am working on several fronts to address this. One small but meaningful effort is to encourage employees to read. Recently I sent every IT team member a Barnes and Noble gift card so they can get a book. The only thing I asked in return is that they post a short book review on our internal social networking site (we user Yammer). Some bought traditional books, some of our road warriors bought audio books and others bought ebooks for their nook.

I love the Dave Ramsey quote: “You are the same today as you’ll be in five years except for two things: the books you read and the people you meet.”

I told my team that the book did not have to be related to their work. I did not want people to buy SQL Server Administrator guides that would collect dust on a shelf next to the Lotus 1-2-3 floppies. As I have have blogged in the past, inspiration will come from unlikely sources as long as you are open to it.

To that end I just finished Operation Mincemeat. This is a wonderful non-fiction account of a British WWII deception plot. Toward the end of the book I was struck by this quote:

“Wars are won by men…storming up the beach with all guns blazing…They are won by planners correctly calculating how many rations and contraceptives an invading force will need. By tacticians laying out grand strategy. By generals inspiring the men they command. By politicians galvinizing the will to fight. And, by writers putting war into words.”

At the risk of being overly dramatic, it strikes me that large IT projects (like an EHR) are similar. They need champions willing to take on risks; great planners; people that envision how the system will serve a larger strategy; people at the top that can motivate the team and the users; and people communicating the right message to the right target audience. Contraceptives are probably not so important.

I am also developing a multi-day curriculum for IT Analysts that will make them more effective project leaders and team members. It is essentially a brain dump of everything our IT veterans have learned (often the hard way) implementing healthcare IT systems. I am thinking about opening it up to people outside of our organization. Let me know if you think there would be an interest.

What about Care Planning?

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In the world of hospital information technology, automated care planning is as under-appreciated and Computerized Physician Order Entry is over-hyped. Typically care planning software was used outside of the care process to produce documentation for Joint Commission (JCAHO) surveys. This is not the promise of good care planning software.

The care plan should be the plan produced by all disciplines, and led by the physician, that defines the goals of the patient stay and ensures that all of the key interventions take place at the optimal time in order to achieve those goals as quickly as possible (shortest length of stay) with the least amount of resources (lowest cost). The care plan is the hospital’s assembly line. I believe it is the most important element of nursing informatics.

Focusing on medication process automation and Computerized Physician Order Entry (CPOE), to the exclusion of good care planning automation, is like a car company that wants to build really good tires and engines, but does not have a way to build a car in a timely, defect-free manner.

I believe nurses, no – all care givers, need a single dashboard where they can see every intervention (including administering post-operative antibiotics, ambulating patients, assessing skin, patient education, etc,). That dashboard can function as the caregivers worklist presenting the tasks to be completed in the most efficient sequence by the most appropriate member of the care team

Additionally, all of the care plans could be monitored centrally to identify key interventions that have been missed (think population management for inpatients). This would allow interventions of key quality indicators before it is too late, as opposed to the status quo where the quality indicators are available 6 weeks after the patient is discharged and coded.

Why isn’t care planning an element of meaningful use? In my opinion, It holds more promise to manage cost and achieve outcomes than CPOE.

Getting Your EHR and Eating It Too

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For year’s EHR vendors created EHR shells with  functionality that lacked all of the creamy goodness of evidence based medicine.  Instead they have left it up to the hospitals to do this.

This has not worked well. Who wants to buy the cream puff shells at the bakery then go home to make your filling? I just want a damn cream puff. Adding the evidence-based medicine to an EHR is an amazing amount of work that literally takes a decade before the average health care organization can scratch the surface.

I read this blog post today that describes Cerner’s plans to use British Medical Journal (BMJ) clinical content: http://bit.ly/9vJEfb. Dale Sanders, CIO, Cayman Island Health Authority has written an excellent post with exuberance.

This seems to be much more connected and thought out than the pseudo-partnerships we see today between EHR vendor’s and tools such as Zynx.

This is the kind of thing that can be disruptive to the EHR market. That is, it could knock Epic off the top of the mountain.

Home Phone Challenges in Patient Registration

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I was speaking to some of the folks that head up admissions and registration at Affinity Health System this week. They shared with me that recently it has become very common for patients to have to look up their home phone numbers when registering. Usually they look it up on their cell phones.

I can think of a couple of times recently when I could not rattle off my home phone number like I had my entire life. I am glad to hear that this is the result of the shift in reliance to mobile phones, rather than my approach to age 50 (at least that is my claim).

In the future we will all be like Einstein.

Reaction to the Final Rule EHR Incentives

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On July 13, 2010 the Center for Medicare and Medicaid Services released their Final Rule regarding the Electronic Health Record Incentive Program, known within our industry as the definition of “meaningful use” of an EHR.

Senator Russ Feingold’s office contacted Ministry Health Care to get our reaction to the regulations. We greatly appreciate the Senator taking the time find out how such rulings impact our organization and our ability to live out our mission of improving the health of the patients we serve, especially the poor. Here is our response:

Thank you for asking for Ministry Health Care’s reaction to the Final Rule on HIT – Meaningful Use.

Our overall reaction is favorable.  While there may still be challenges associated with timing and certification, we do believe some specific comments from Ministry Health Care and others were heard and addressed in the Final Rule.

Under the Draft Rule, we viewed the Meaningful Use regulations as a disincentive, requiring too-much-too-quickly for an entire healthcare industry.  Given the changes in the Final Rule, we are re-evaluating our plans with an eye toward accelerating Electronic Health Record plans at many of our hospitals.  This is good news for our patients!

The true measure for us is Ministry Saint Clare’s Hospital in Weston.  Under the Draft Rule, Ministry was challenged just to reach Stage 1 meaningful use in Weston, where Ministry Saint Clare’s is Wisconsin’s first all-digital hospital and the only hospital in the state recognized by The Leapfrog Group as having fully implemented Computerized Physician Order Entry (CPOE) (by the way, the invitation for the Senator to visit Ministry Saint Clare’s to see this firsthand is always open).  This was a sign that the originally-proposed incentives were not rational.  Under the changes in the Final Rule, the path to Stage 1 meaningful use is more easily accomplished for Ministry Saint Clare’s: Wisconsin’s most IT-advanced hospital that has been perfecting its EHR since opening in 2005.

Likewise, Ministry Medical Group would not have been able to easily achieve Stage 1 meaningful use despite our project to deploy the Marshfield Clinic’s EHR (CattailsMD). We were not sure that the 1,000 Wisconsin doctors were going to be able to receive EHR incentives using that system.  Under the Final Rule, we feel there is an achievable effort to reach Stage 1 Meaningful Use, which is an incentive to start improving the system in order to meet Stage 2.

Our only significant concern at this point in time is the EHR certification process.  We are now nine weeks from the October 1, 2010 start of the EHR Incentive Program, and none of the EHR products on the market today are certified to meet Stage 1 meaningful use criteria.  As of today, ONC has yet to identify an Authorized Certification Body.

Ministry could implement the most sophisticated and beneficial Electronic Health Record in the world and still be denied EHR incentive payments due to the EHR certification requirements.  These requirements, in our opinion, have not been well defined or well conceived.  The certification process does not seem to take into consideration that a large sophisticated health system, such as Ministry, implements EHRs using a combination of commercial products and internal software development.  While no single piece of the puzzle is a certified EHR, the combination of these solutions result in an Electronic Health Record that exceeds the certification requirements.  The uncertainty over the certification process is now a much greater concern than the final meaningful use requirements.

Can Someone Decipher This ONC Guidance?

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On July 6, 2010 the The Office of the National Coordinator for Health Information Technology (ONC) sent written guidance to states and state designated entities regarding HIEs:

Executing Strategy for Supporting Meaningful Use

Operational plans shall describe how the state will execute the state’s overall strategy for supporting Stage 1 meaningful use including how to fill gaps identified in the environmental scan.  Specifically, states and SDEs shall describe how they will invest federal dollars and associated matching funds to enable eligible providers to have at least one option for each of these Stage 1 meaningful use requirements in 2011:

  1. E-prescribing
  2. Receipt of structured lab results
  3. Sharing patient care summaries across unaffiliated organizations

I first heard about this guidance to the states about a month ago. At the time I was puzzled how ONC thought state HIEs would ever be involved in ePrescribing. Providers do not need assistance from the HIEs to implement ePrescribing.  This is solely the domain of the provider EHR and the existing Pharmacy exchange managed by SureScripts. I thought that they would realize this and back away, but surprisingly it made it to writing.

So, what does ONC expect the state-designated HIE to do regarding ePrescribing? If you read the entire Program Information Note there isn’t any sort of clue. Does anyone have any insight regarding this?

Why Change Management Matters

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I used to think that change management was something you did for the auditors. I now realize that my attitude was undermining the value and that Change Management is the most important control in an IT department.

Kevin Behr (kevinbehr.com) opened my eyes. In Visible Ops Behr, et. al. state that 80% of all IT problems are the result of something we changed (shooting ourselves in the foot). Creating a culture that values successful changes and backs out bad changes rather then “fixing” the problem creates a more efficient IT organization.

I could continue plagiarizing from Visible Ops, but this note from our Exchange guru says it all:

Change management saves the day and my vacation! I have been working on a pesky issue  today that I thought was limited to one resource mailbox but turned out to affect other mailboxes of that type. While working closely with the impacted users we were able to determine the problem started last week.  I reviewed my changes from that time frame and there it was!  A minor change made to correct one issue caused another issue.  Before finding that change documentation I was worried there was a larger issue going on that would require resolution before I could leave for vacation.  Long story short, issue resolved.  The extra time taken to document changes pays off big time and  I’m outta here! Have a  great 4th of July.

Whose Cost?

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As each state prepares to launch Health Information Exchanges (HIEs), it is important to keep in mind the goals of the effort.  I believe this is more difficult than one may think at first blush. But, trustees of these HIEs need to move beyond a “motherhood and apple pie” approach of saying the purpose of an HIE is to reduce cost and improve quality and safety.

The cost question is very complicated. After all, one stakeholder’s expense is another’s revenue. Is the goal to reduce the cost to the State? The Patient? The Payors? The Providers of healthcare?

Take duplicate testing. Certainly an HIE has the ability to enable the reduction of duplicate testing by giving providers instant access to results stored in other providers Electronic Health Records. That is a win for the Patients, States and Payors. But, that will have an impact on provider revenue. If the HIE requires all parties to mutually support initiatives there is a strong potential for stalemate.

To complicate this even further…just because a provider has access to the results from another provider does not prevent the provider from ordering a duplicate test. I have overheard other organizations leaders suggest that they should not trust results from other providers and that re-ordering expensive tests is the best care. Unless the HIEs tackle that concern they may not achieve the benefits that they seek.